Weight Loss and Recovery—Can they Coexist? Is Recovery Even Possible After So Long?

Remember Maggie who lost over 150 lbs.?

She’s experienced them all—she’s been labeled with anorexia, bulimia and BED (binge eating disorder)—now an official diagnosis in the new DSM-5, the manual of mental health diagnoses. And she’s been categorized as obese. She did not seek treatment for her disorders early in her history, when recovery is known to be more likely. Yet she’s done it, she recovered. And she didn’t truly start the process until she was in her 60’s.

Hooray for Maggie! Recovery is possible!

I'm writing about Maggie, once again, to offer hope that recovery is possible. Because it is. And because you may believe that even if you did recover, that you would never maintain it. And that it’s not even worth starting on the path, because you just might fail. There. I’ve said it. Now let’s move on.

About Maggie, present day.

This lovely, now 74-year old woman with a long history of eating disorders, has maintained her consistent recovery—and then some. If you haven’t read about her history through Feb 2011 in the link above, please read it now to appreciate where she’s been.

First, the stats. As of today, Maggie's weight is down from her initial weight of 387 pounds (back in 2002 when we started our work together) to 212 lbs. Yup, that's 175 lb. decrease. Most notable, though, is that she achieved this through healthy measures, normalized food intake, a move from binge eating and without disordered behaviors. I don’t think you’ll find the Biggest Loser winners accomplishing such behavioral goals, given the crazy-extreme measures they take on the show.

But let's look at the markers of health that really matter: her A1c, the measure of blood sugar control over a three month period, is now normal for this diabetic woman (it was out of acceptable range even for diabetics, previously). And she is no longer on the blood sugar-lowering medications she had relied on twice daily. All of her lipid measures (think cholesterol) dramatically improved, too. ‘Maybe it's the meds?’ ‘Don't statins do a great job at that?’ Well, her statin dose was cut in half. And statins do little to nothing to improve HDL, the 'good' cholesterol—yet hers improved significantly. As did her triglycerides (down 150 points), also not attributable to her medication! At 212 pounds, her cardiac risk ratio is lower than most individuals’ by far.

Maggie eats more than she ever recalls allowing herself to eat at any other time in her life—aside from pregnancy. She consumes regular meals and snacks daily. She does a water exercise program a couple of times per week—she's even overcome her anxiety of being in the water, with the assistance of a great therapist.

It's a lot of hard work, and you might get off course.
But you'll be glad to get there in the end.

It's been neither a few months, nor a whole year. Rather, it's been 11 years since we started our work together. Yes, it's a process (although not this long for everyone, I'll add). But Maggie only started her journey when she was 62, after about 50 plus years living with disordered eating and beliefs about what she deserved to eat and how to nourish her body.

Patience, dear readers. You can’t expect to undo a decade or a lifetime of unhealthy thoughts and behaviors in a couple of months.

Maggie’s next step is to believe that she's just fine as she is—high BMI and all; that weight loss shouldn't be the focus. It’s not so easy, though, given that her whole life her worth was tied up in the number on the scale. Even when those who constantly criticized her appearance were gone, she picked up where they left off with her own negative self-talk. It seemed the damage was done.

But can’t she still lose weight?

If she continues with her eating on course, and she feels well, and her weight continues to decrease—there's no problem with losing more weight, as long as her thoughts are kept in check. But I'm emphasizing that the goals that really need to be met, have been: she's taken control of her health, she's more fit than she's been in years, and she's eating more adequately than ever before. There's no binging or deprivation, and no compulsive exercise. And she feels well—physically and mentally. So we’ll just need to proceed with caution, because weight loss is a slippery slope for triggering eating disorders.

I hope Maggie will check out this blog (she has given me permission to write about her again, with her name change of course!) And I anticipate she'll see from your comments how she has inspired you and others to not give up and to have hope that change is possible. Yes, recovery really is possible.

Please share your thoughts with us!

Following a Vegan Diet. And, a Gluten Free Diet. And, and, and…

Couldn't Resist This Photo Op In Switzerland!

It’s time for some praise for doctors. Surprised? I know you are used to my airing my complaints here, for inappropriate, unconstructive assumptions some doctors make. And, for their misinformation not infrequently conveyed to patients, when it comes to diet and disease management. Just last week, a patient with type 2 diabetes shared her experience about her follow up MD visit. Jane has been eating well, resulting in a significant and appropriate weight loss. She’s moving more, and watching her carbohydrate intake, improving her post meal blood sugars. But given that her morning numbers remained quite high, in spite of her fabulous lifestyle changes, I encouraged her to address this with her doctor, hoping for a shake up in her diabetes medications.

Can you guess what he told her? 

You guessed it. Just lose weight. Yes, he wanted her to continue to stay with sugars almost 100 points too high, potentially causing damage to her blood vessels and her organs. Perhaps continued weight change will improve her sugars—but that takes time, and with the 50 or so pounds she has already lost, the numbers haven’t changed significantly. But it’s easier to pin the responsibility on the patient to change.

Oops! I was planning on praising a doctor today!

The wisdom of Dr. Mars

His patient was not an obvious referral for nutrition counseling. She did not present with any complaints about her health, and her rudimentary labs did not flag any concerns of disease in the works—normal cholesterol, blood sugar, thyroid, to name few. Other, more detailed nutrient assessment is pending. Her blood pressure is fine, low in fact, with that “healthy runner’s pulse”. And her weight? It had dropped from her usual place many years ago, from the normal range, when she had been diagnosed with cancer, now in remission; but it had increased somewhat since then.

“What brings you here?” I asked, as it was not so clear, at first glance. “Dr. Mars suggested I get in to see you”, she replied.  “His concerns?” I continued. “He’d like you to assess my diet and be sure it’s adequate.” Fair enough, I thought.

At least she's left with these--if they're uncooked!

And here’s what I heard. Di moved from a vegetarian diet to a vegan diet some years ago, presumably to be healthier. She then cut out soy products because of inconclusive evidence of a link between soy and some cancer. Only she did not have the type of cancer that might have even been impacted by soy. She then decided that she should cut out gluten, because she thought she might be allergic. She didn’t notice any change, but had heard (from reliable sources, no doubt) that it helps. So she stuck with it. Rumor had it (Hollywood tabloids, perhaps?) that the raw food diet was a means to extend life and stay fit, so she tacked on those rules too. 

I’m not sure I could have created such a patient from my imagination. The only thing she hadn’t reportedly restricted was fats. But judging by her food selection her intake of fat was quite low, unhealthily low. Oh, how wise of Dr. Mars to send her my way!

My confession

We do the craziest things for our cause.

I get it, at least to some extent. If you’ve been handed a diagnosis for which there is no cure, or one which can easily take your life, you feel quite vulnerable. So anything you can do to potentially help your situation makes perfect sense. And so early in my diagnosis with Multiple Sclerosis I embarked on my own gluten free adventure. Armed with anecdotes spread across the Internet, I was determined to take charge of my condition in any way I could. I knew that the science was sketchy, at best, in its infancy in fact. Much had been written about other auto-immune conditions and the benefits of a gluten free diet, but little to no research existed for MS. I had my MD check my labs, which revealed some abnormal levels—so maybe there was a link, I thought. Celiac experts (those that address the autoimmune disease truly caused by consuming gluten) dismissed these labs as inconclusive, but I was determined.

Three months of strict adherence to a gluten-free diet cured my MS!

Don’t I wish! Rather, meticulously following a gluten-free diet was a constant reminder that I lived with this medical condition; kind of like following a meal plan with an eating disorder. But if it worked, I would follow it forever. Only it didn’t work. Sure, I felt I was taking charge, doing my part to control my disease. But in those three months I had more new lesions on my brain and spinal column than perhaps at any other time in my 9 years with MS.

There’s a point you have to ask yourself “Is this strategy working for me?” Is it really meeting the need I intended it to meet?

 Gluten-free failed. But fundraising and riding with my team of friends and
family (almost half of whom are MDs) has helped me enormously.

Did Di’s strategy improve her health with her myriad of diets rules? Hardly! She now had irregular periods (potentially due to a low percent body fat), and she likely will be experiencing muscle wasting, as her total calories and total protein are insufficient for her need. Osteoporosis or osteopenia , its precursor, is inevitable, with her low calcium intake and vitamin D, and with her questionable estrogen levels, given erratic periods. I could go on listing the pitfalls of her diet, but I think you get the point.

Focusing on her food rules may very well work for Di—on some level. But if she allows herself to be honest, she’ll realize that this is not a healthy diet at all.

And you?

Is it time to reexamine your own patterns of eating or food rules? Are your eating behaviors really working for you? And is it in your hands to change?

I’d love to hear from you.

Thanks for reading and for giving me your invaluable feedback!

Why Bother? Patient Lessons.

Tuesday With Marla

Gotta love her attitude!

Why bother? That’s what I thought. I worked hard on making changes, and in spite of my efforts, here’s the bland response I got from my doctor in this letter: “Your A1c is fine. Your lipids are high. LDL 105, HDL 46, Triglycerides 167. Stay on the statin. Continue to work on your diet and exercise.” If we hadn’t already discussed these results together, you and I, I would have just blown it, food wise.”

What’s this all about, you’re wondering? Let me fill you in. Marla has been working with me for about 8 months. She presented to me with high cholesterol, high blood pressure, and obesity. And her A1c, the blood test that gives a picture of blood sugar control over a three-month period, was just about out of range when she first came to see me. But most distressing to her, was her relationship with food, her struggle with binge eating disorder. Her emotional triggers were real, and life continues to have its share of stressors.

So what happened to Marla?

Here’s the quick summary, based on the concrete facts, the numbers, first. Her A1c dropped into the normal range, several points below where it started. And several points, on the A1c scale, is a pretty huge change. Her ratio of total cholesterol to HDL—the good cholesterol—improved significantly; it is now well within the healthy range, below 4.3. And it started at 6.1. Her good cholesterol is higher than ever, about 40% higher, likely the result of the significant improvement in her activity level. Of course I shared this great news with her at our recent session, expressing how pleased I was that she achieved this dramatic improvement while simultaneously reducing her dose of statins, the cholesterol medication she had been on from the start.

And while her BMI remains high, she is down 43 pounds. And get this—her food record today revealed proudly inclusion of Pay Days, the mini Halloween sized candy bars she gets on sale after Halloween. One or two at snack were consumed when she needed to eat, when she got hungry. And she ate them for many days, I’ll add.

Why so proud to be consuming these chocolate peanut candy bars? I’ll tell you.

Keeping dessert in balance, Marla now can enjoy her favorites.
These, though, are mine-homemade French macarons.

Because, as Marla stated, “Just last year, I thought that once I started I couldn’t stop—because that was what would happen—in the past. I’d find a trail of Pay Day wrappers strewn about my apartment, unaware of just how many I had eaten throughout the evening. Now, I’m not in deprivation mode. And I can record (and acknowledge) that I ate them. And I can eat them in moderation, and enjoy every bite.”

But when Marla saw the doctor’s letter, she had to work hard to remind herself that she really had done well, regardless of how his summary distorted things. “Lipids are high”? They are not only significantly improved, but almost all the values are now in the normal range. “A1c is fine”? How about “Job well done! You are now in the normal range as a result of your hard work! ? Marla had gone from a fatalistic approach about her health—she shared that she never expected she might outlive her relatives, many of whom passed on in their 50s of heart disease. And when she first saw the doctor’s letter she assumed, once again, why bother? I guess I can’t change the situation. She assumed that genetics tell all—her high levels were just meant to be, and there was little she could do about them. But now she knows that is not so.

Why bother?

Even if her levels hadn’t improved (which of course they had), was it really a “why bother” situation? Certainly not! She felt more in control of her food, was able to include whatever she liked now, in reasonable amounts, and was more fit than ever, with her increased activity. She felt physically better having lost weight, and mentally, was in a better place. And she was taking an active role in her health, rather than assume her fate was sealed because of genetics.

And then there was Sarah.

from the MOMA, NYC

Sarah, in her mid twenties, presented yet another “Why bother?” to me last week. (Was it a full moon, or just one of those weeks?) She has been working on recovery from anorexia and bulimia. Medically stable, she has been out of an eating disorder program for several months, since we began our work together.  And she’s doing quite well, I might add. There’s no crisis now, no flames to put out, no imminent need to push her self. Yet she still needs to continue her work to gain weight, to move into an appropriate weight range.

In our last session it struck me (us?)— getting healthier has its risks. It means she can’t blame any failures (such as not getting into grad school, or moving forward in a career, or in life) on her eating disorder. And recovery has another downside. When you peel away the eating disorder—the restrictive eating and thoughts or the binge eating—you are left having to feel. And quite frankly, feeling doesn’t always feel so great.

So why bother?

No, this is not me! But I did capture this amazing sight in Switzerland.

Because once you get to this better place with food and your health, and get support for managing those painful feelings, life is more fulfilling. You can rediscover your passions, and get more out of living. You can feel that what you do in the world makes a difference. And you can be more present to enjoy the people around you whom you care about.

Marla could have accepted her assumptions that there’s nothing she could do to change her course—but she didn’t. And the results, on all levels, speak to the benefit of her bothering.

In Sarah’s case, it’s possible that in spite of her eating disorder recovery, she may not get into the grad school of her choice. But without recovery, it is a guarantee for ultimate failure.

Life’s too short to not live it to the fullest. 

The Lies They're Feeding You About Your Weight and Health

 And, what you can do about it

Blatant misinformation comes from perhaps the least likely sources, including well-intentioned doctors and the media. Unaware, you continue to be misinformed about your weight, your eating and their impact on your health. Let's take my patient Dave. A pleasant, driven man in his late 60s, Dave takes medical advice to heart. He has a history of high blood pressure, for which he takes medication, religiously. Yet his pressure remains too high. So his doctor told him "You gotta lose weight, Dave, and your pressure will get under control." Reasonable enough, right?

I think not.  Now only 8 or 10 pounds above his college weight (pretty good, I'd say, given his age), here's a little secret about Dave’s blood pressure--it was elevated even when his weight was at its lowest, back in his early 20's, when his weight was just fine. Oh, and did I mention Joe's fitness level? Despite being in his seventh decade of life, Dave runs 6-8 miles, 5-6 days per week, and he's been doing so for years.

Great art. Terribly high sodium content.

From Dave’s perspective, his referral to me was a blessing in disguise. He's learned that his sodium intake was way too high—3-4 times the recommended level for those with hypertension. Reducing his sodium intake may have much more of an impact than simply losing weight. To focus on his weight was simply foolish, as his weight, historically has had no bearing on his blood pressure. If he put his energy into losing weight and then his blood pressure remained high (as I'd expect given his history) he would feel like a failure. Changing his food choices, however, reducing his very high sodium intake would increase his odds of normalizing his pressure.

Thinking it's all about sodium? Not so fast. Here's a bit more personal story. My father, when he was in his 20s developed high blood pressure, as well as pre-diabetes. He was a normal (actual rather slim) weight, and was active, as he walked everywhere. His father and grandfather before him had Type 2 Diabetes, although I am unsure about their blood pressure. When I was in my 20s I had my first bout of hypertension, which I blamed on the crazy level of stress at my first job. But in fairness, even years later, I still have high blood pressure.

My Dad, 26 who survived his diabetes
and high blood pressure and died of lung
cancer (no, he didn't smoke)

Managed with diet? Exercise? Isn't that what you'd expect from a dietitian? Not so! For the record, I am in a normal weight range, and I watch my sodium. My eating (besides the cake you so often hear about) tends towards freshly prepared food, with lots of fruit, vegetables, grains, and nuts, and my fair share of my favorite oils (olive, walnut and truffle). And yes, I am active. So basically, my healthy diet, normal weight and exercise have done nothing for managing my blood pressure. Thank goodness for meds! But perhaps my healthy lifestyle, in spite of my genetics, may be helping to prevent diabetes.

Me & Mom in NYC

And then there's my mother. I won't mention the dreaded O word, but let's just say that her current BMI qualifies her for gastric bypass. Oh, and that's even after the procedure was done some years ago. And even at her highest weight, prior to her surgery, her blood pressure and cholesterol were always perfect. She actually eats rather well, but does no regular exercise. She does have knee problems, perhaps due to years of carrying the extra weight, perhaps not. Did I mention I also have knee problems?

Now don't get me wrong. I am not suggesting that obesity has no impact on your health, physical and emotional. That is simply false. It increases the risk of Type 2 diabetes, high blood pressure, and cardiac risk. It also contributes to knee and joint problems and has been associated with breast cancer. It presents challenges when people are trying to travel--renting small European cars, for instance, sitting on airplane seats—and in dealing with social stigma and job discrimination. I certainly support making practical, realistic changes to feel better on all levels—eating healthier, being more fit, lowering your stress, getting more sleep. But the focus should be on the impact of those lifestyle changes on your quality of life now, today. If you're motivated simply to lower your blood pressure, you may be disappointed if the outcome isn't as expected.

Not fitting for everyone.

It's like the many clients I see who report a history of starting to exercise. After a short time, they fail to see the weight loss they were expecting for any number of reasons. And so they stop exercising. They forget that there were clear benefits they experienced from exercise—lower stress, better sleep, better mood, greater energy, to name a few. But with a singular focus on exercise to drop pounds fast, they had failed. And so they stopped exercising, giving up all the benefits they were getting from it. How quickly they forget.

Try to change what's in your hands to change, to feel better and to potentially lower your risk of and from chronic disease. And it helps to focus on the imminent changes—those immediate benefits you can see, and feel and experience—not just the benefits far in the future. Those, too, are important, but it’s much harder to motivate for those off-in-the-distance benefits that you can’t even feel.

But if in the end you need to add a medication to keep you healthy, accept (without guilt) that you have done your part, and continue your healthy lifestyle changes because of all the benefits it brings you. This applies to those who are overweight, as well as those with restrictive eating disorders. You need to do your part, in addition to using all available resources as well.

Biking and fundraising for MS with a little help from my friends.

While perhaps unrelated to the weight struggle, I will share one more personal piece. Nine years ago this month I experienced my first symptom that led to my diagnosis of MS (multiple sclerosis). This unpredictable disease is not caused by lifestyle changes, and does not run in my family. Yet while diet and exercise neither cause nor cure MS, they can certainly allow me to stay healthy on all fronts. I don't live with the illusion that my actions will cure my disease, but I can appreciate that I feel well doing what I am doing, and taking control, in a healthy way, of those aspects of my health I can control.

Thanks to Quincy Carole for a past comment, prompting this post!

Thanks for reading.